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Acute abdominal and pelvic pain in pregnancy: ESUR recommendations

Abstract

Acute abdominal pain in pregnancy presents diagnostic and therapeutic challenges. Standard imaging techniques need to be adapted to reduce harm to the fetus from X-rays due to their teratogenic and carcinogenic potential. Ultrasound remains the primary imaging investigation of the pregnant abdomen. Magnetic resonance imaging (MRI) has been shown to be useful in the diagnosis of gynaecological and obstetric problems during pregnancy and in the setting of acute abdomen during pregnancy. MRI overcomes some of the limitations of ultrasound, mainly the size of the gravid uterus. MRI poses theoretical risks to the fetus and care must be taken to minimise these with the avoidance of contrast agents. This article reviews the evolving imaging and clinical literature on appropriate investigation of acute abdominal and pelvic pain during established intrauterine pregnancy, addressing its common causes. Guidelines based on the current literature and on the accumulated clinico-radiological experience of the European Society of Urogenital Radiology (ESUR) working group are proposed for imaging these suspected conditions.

Key Points

Ultrasound and MRI are the preferred investigations for abdominal pain during pregnancy.

Ultrasound remains the primary imaging investigation because of availability and portability.

MRI helps differentiate causes of abdominopelvic pain when ultrasound is inconclusive.

If MRI cannot be performed, low-dose CT may be necessary.

Following severe trauma, CT cannot be delayed because of radiation concerns.

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Correspondence to Gabriele Masselli.

Synopsis and key recommendations for imaging pregnant patients with acute abdominal and pelvic pain

Synopsis and key recommendations for imaging pregnant patients with acute abdominal and pelvic pain

  1. 1.

    Imaging techniques

    • Ultrasound remains the primary imaging investigation because of availability and portability, but it can be limited because of altered body habitus, small field of view and the presence of interfering overlying structures.

    • MRI helps differentiate causes of abdominopelvic pain when ultrasound is inconclusive.

    • Following severe trauma, CT cannot be delayed because of radiation concerns.

  2. 2.

    Optimal MR protocol

    • Breath hold multiplanar T2-weighted sequences based on the half-Fourier reconstruction technique, and the balanced gradient-echo sequences and axial and sagittal T1-weighted GRE and diffusion sequences.

  3. 3.

    Recommendations for clinical practice

Placental abruption

MRI should be considered after negative ultrasound findings when there is high clinical suspicion and when a firm diagnosis of abruption would change clinical management.

Placenta adhesive disorders

Ultrasound in patients with clinical risk factors and then proceeding to MR imaging for equivocal cases especially in patients with posterior placenta and previous myomectomy.

Uterine rupture

MRI to diagnose ante-partum uterine rupture in patients with indeterminate ultrasound evidence, showing the tear itself and other uterine wall defects including uterine dehiscence.

Adnexal mass

Most masses can be accurately assessed by ultrasound; however, MR imaging can provide further characterisation, particularly for evaluating their haemorrhagic content.

Leiomyoma

Ultrasound is accurate in most cases. Perform MRI if any difficulty differentiating from an adnexal mass.

Ovarian torsion

Magnetic resonance imaging should be performed after inconclusive ultrasound and can detect hemorrhagic infarction.

Urolithiasis

Ultrasound is the first imaging test despite its substantial limitations.

Magnetic resonance urography (MRU) differentiates physiological urinary tract dilatation from abnormal dilatation related to urolithiasis.

In unresolved cases, CT remains a reliable technique for depicting obstructing urinary tract calculi in pregnant women.

Appendicitis

Ultrasound can be limited by the pregnant body habitus, especially in the later stages of gestation. MR should be performed in case of inconclusive ultrasound.

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Masselli, G., Derchi, L., McHugo, J. et al. Acute abdominal and pelvic pain in pregnancy: ESUR recommendations. Eur Radiol 23, 3485–3500 (2013). https://doi.org/10.1007/s00330-013-2987-7

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Keywords

  • Acute abdominal pain
  • Pregnancy
  • Guidelines
  • Ultrasound
  • Magnetic resonance